1. Technical Field
This invention relates in general to health care and, more particularly, to a healthcare information system.
2. Description of the Related Art
A significant problem in providing health care services is the confirmation process which ensures that a patient's health plan coverage is appropriate to cover the health services to be rendered. A health plan has certain characteristics that define the benefits for the eligible patient and informational requirements for the eligible patient to obtain those benefits. The following are typical:
A. Effective dates or period of coverage
B. Cost sharing                1. Co-pay office visit        2. Co-pay emergency visit        3. Deductible        
C. Covered services                1. Approved Healthcare providers                    a. Primary care physicians            b. Specialty physician            c. Hospitals            d. Pharmacies and suppliers of medical equipment            e. Free standing laboratory and radiology facilities            f. Home health providers            g. Long-term and special care centers                        2. Procedures or diagnostic test based on clinical criteria        3. Formats for obtaining authorization for referral to approved providers                    a. Printed forms that are filled in and faxed            b. Telephone processes using dialtone input            c. Telephone process using person to person information exchange            d. Web based forms            e. Direct electronic data interface devices (EDI).                        4. Information required for referral authorization                    a. Primary physician name            b. Primary physician plan ID number            c. Primary physician address, fax and phone number            d. Referred to provider's name            e. Referred to provider's plan ID number            f. Referred to provider's address            g. Diagnostic and procedure codes            h. Member's plan ID, name and date of birth                        
D. Billing information                1. Employer sponsor        2. Responsible person or policy holder        3. Persons covered under policy holder        4. Mailing address        5. Approved format                    a. Printed forms            b. Electronic claims submission (EDI)                        6. Time period for claim submission        7. Identification numbers (policy and group)        
(A), (B) and (D.1–4) are usually printed on the patient's insurance card. Most other information is usually contained in the manual the provider receives after contracting with the given health plan. (C.1.a–c) may be in a manual carried by the patient and (C.2.) may be in the form of instructions on contacting the plan with medical information before the procedure or test is approved.
Ideally, a patient presents to the provider with the insurance card. The patient is billed for the co-pay on the card and the remaining deductible. If a referral is required, the patient is sent to the approved provider and the bill is submitted, as instructed in the manual. In practice, the following errors, omissions or delays occur:
A. The patient may give or present information that he is covered when he is not.
B. The patient may not have a card, the card may be out-dated, or invalid.
C. The patient may be on a contracted health plan, which is administered by a third party or employer, and has different billing information than the typical health plan.
D. Determining approved providers for referral:                1. Changes may have occurred since the last printing of the manual.        2. Providers may be listed only in the patient's manual, which is unavailable.        3. Providers may be listed only by county, without regard to specific location or hospital affiliation, if admission is required.        
E. Billing information may have changed since the last printing of the manual.
F. Clerical staff may introduce errors or omissions by manual data input.
Traditionally, the insurance information for the patient is entered manually in the patient record when he presents to the office. After the patient's visit, his financial obligation is billed to him and a claim is submitted to the carrier according to written instruction. The acceptance or rejection of the submitted claim usually determines eligibility or verification that a patient is on a health plan. This occurs either by mail or electronic claims submission. It may also be done by telephone, which tie up staff from other duties.
Health insurance plans that manage patients' care do so by restricting the patient to providers approved by the plan. In general, when a patient requires care beyond that of the primary physician, the plan will reimburse those providers who are approved by the plan for referrals made by the primary physician. The process whereby an insurance plan acknowledges this care will be reimbursed is generally referred to as “authorization”. Authorization may require only that the primary physician fax or mail a form containing information to them, or it may require the submission of specific information and issue a specific authorization number prior to approving reimbursement for services requested by the referral.
Each plan has a specific process and may allow multiple processes (C.3.). When a referral is suggested to a patient by their primary physician, the most common practice is for the patient find, and make an appointment with, a plan approved provider. After the appointment is made, the patient calls the primary physician's office with the name of the provider and the appointment date. The primary physician then completes the authorization process required by the plan and faxes the authorization number to the referred to provider. In most cases, the referred to provider will require documentation of authorization before accepting plan reimbursement for services provided to the patient.
In this regard, (C.3.a.) may be supplied by the insurance plan as printed forms which the provider copies, completes and then faxes back to the insurance plan. (C.3.b–c) are usually written procedures supplied to the provider by the plan and often with a printed template that can be copied and used for exchanging information over the telephone. (C.3.d) is software or procedures for using a web base browser that enable a provider to complete the referral on a “web page”. (C.3.e) are proprietary input devices such as a “swipe card reader” terminal that use an EDI connection.
Completing the authorization process involves many time consuming procedures involving required information(C.4.). When submitted forms are used, they are usually completed by hand since many require boxes to be “blacked out” to be read later by optical character recognition devices. Redundant information must be manually entered on each form (4.a–c). Other types of information require that manuals be searched for the various numbers(4.d–g). For authorizations requiring a specific authorization number from the plan, the staff usually contacts the plan by phone using a manual dialtone entry procedure. Most dialtone processes will terminate unless the required numbers are rapidly entered in a certain sequence. To avoid termination, the staff must fill out a form or template to prepare for entering the information. Web based forms require Internet dialup for each session unless the office has a dedicated connection. EDI devices serve only a limited number of plans participating with companies providing the necessary equipment.
This system has significant adverse consequences. For the confirmation of health plan eligibility, real time confirmation (typically by telephone), and referral authorization, consumes the staff time of both provider and health plan and confirmation by claims submission increases the billing cycle and produces duplication of effort. The manual data input increases time spent by patient and staff and produces a higher error rate than automated entry. Incorrect co-pay or deductible results in under and over-charging requiring rebilling and refunding procedures. Incorrect patient address results in delayed or non-collection of charges. Incorrect billing information results in the claim being returned and delayed, rebilling procedures, and sometimes loss of charges due to time factors. Inability to quickly and accurately identify approved providers for referral may results in increased staff work to search and call for information and delays in patient care. Referral to a non-approved provider may result in increased staff work required correcting the referral, non-payment by the health plan to the “non-approved” provider who then charges the patient and higher than usual charges from the “non-approved” provider made to the health plan.
Incorrect information provided by a patient at one provider may be repeated at other providers. This results in a cycle of redundant information correction, at multiple providers, for a single error.
A limited number of online systems (Internet or direct dial-up) provide the ability for a provider to connect with a database server that has some of the information listed in the first section. These databases only contain information that is shared with them by a health insurance carrier or plan which has an agreement to do so. Updated information is supplied only by the insurance carrier or health plan. Healthcare providers access these systems when the patient arrives at the office, or after the patient has been treated.
These online systems also have server-related problems. The server or connection may be unavailable or slow, and time is spent waiting for connection, unless dedicated line is purchased. The patient's health plan may not share information with the online system, and the patient's health plan may not regularly update information with the online system. Further, the information is typically accessed through a browser interface, which can not automatically export the information into their office management software, requiring increased staff time and error due to manual data input. Referrals made by web browsers must then be printed and manually faxed to the referred to provider.
The speed, and allocation of staff resources, required to give medical care to a patient is dependent upon the accuracy and availability of information pertaining to patients' health plans. Further, the provider's profit for providing medical care is directly related to both the amount of staff resources needed to provide this care, and the efficiency and timeliness of collecting payment for these services.
Current systems suffer from the inability to give the health care provider consistent, timely and accurate information regarding patients' insurance status and requirements. The traditional system can only obtain the correct information after the claim has been submitted or by utilize staff to make telephone calls. Online systems have information that is limited to the health plans agreeing to share data, and is therefore fragmented. It is also subject to disruption in the telecommunications network and restricted in interfacing with the providers' software systems.
Therefore, a need has arisen for a health care information system which provides accurate and timely patient information.